GW1--02753_Well Construction - GW1_20240506

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WELL CONSTRUCTION RECORD Far ttgeriial Pao oxLv:-. •
This form c m beuscd for ofngit of multiple wells �r •
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1.Well COntractor Information: '
::W.WwATER ZONES
Stefan Smith ••: -- • • - FROM 10 DFSCRIPTIO.' I•
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Well Cutir. otNalnn: . - " - ft.: ft 1
3576A . . R. ft. . I
NC-�YcUConitaclorCcnifecalioriNwitaei • �1S.OUTERCASiNG(foratulttca'sedneilsl"ORLiNER{Ifap Stable),
- FnoM -TO : DIAMETER-i' THICKNESS, MATERIAL
SAEDACCO • .f6 • ft.. - •la.
Ca1np,uip Nam.. -16.YNNER""CASING OR TUBING'(gealbermal closcddonpL' .
. - - • - FROM TO v DIAh1ETRR. THICKNESSS MATERIAL '
• 2.Wd1.Consttvctinn Permit tr: R, ft.• a� •
List ill ap(alicnble well per mits.(cc.County.Saato,Variararr.!lariat err.:l .
. :ft." ft. _
3.W ell:Use(cheek Vicll use):. ' . : 17:SCREEN
• Water Supply Well: ' . . . ' FROM. . TO . DIAMETER •St.OTSIZE THICKNESS I MATRRIA1. . .
•• DAgricuintml DDMmucipal/Pub)ir o rt. 10 ft; 1" in .'i:010 sCH-40 PVC •
• .. OGeothetmat¢ieatingiCooling Supply)- ®Residential Water Supply(single)- -ft. ft. in:
• -• Dlndustrial/Conmiercial - '®Residential Water Supply(shared) tPi cRotrl •
FROST TO • AIATERLU. ENIKACE\IENT SIErI1oD S Ah101.1NT '
' ❑itigatian • .ft, • ft. '
'Nan-Water Supply Well:' -
ft... , rt
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-, Ethlonitoring . • • pRcco)ep' •
Injection:Welt: . . . , ft.- . ft. . . . 1,: . • . . . .
0 Aquifer Recharge l7Giouiiditatcr Rcnudiation" . . •19:SANDIGRAVEL•PACK(if a ipIkablc)'.= - -
'FROM' . ' TO • Mnr'RwL -RNIPI,W IENTMF:TnOn •
PAquifcr-Storage.and Rceovet ASalinity Harrier ft., • ft. • 1 . , • .
El Aquifer Test EISlormwatcrDrtinagc" ft. ft. j
l]Espctimr-nt tl Technolpsy 175nb5idCD:c Conitnl 20:DRILLiNG'LOG(attach additional Sheets if necessary)
OGeotltenual(Closed Loop) . • DTracer: • . : .FROM - .TO . - . DFSCRI TIONtyobr.limInc.,:uiwnickti t t. aiu Nile.vita • .
lJGeodieenal(IleatingtCooline Return) ' 1701her(explain under 4121 Retuatks) 0 • ft.• 10 , ft, Sand .
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ft:. fL
4.Date Well(s)Completed 4-16-24 ,Well 1Dlint-9. •-
5a Welt Glcatfrin: •:iL ft, , 1 6 4--,'I-....t. V �.f'
Buckeye ft. . ft, ' MAY 0_G a .4 . . .
Fe Iymth;-rarNanre - . .: Facility IUR(ifappli able) . -
ft,- rt.
4414 Buffalo Rd., Selma, NC, 27576 ft.. ft.: I(;•;O;'n: k i,: t':• 4.;-:�iir
Pltisicnl Addivss City-and Zip C'. C`. Otis . . . .
.- 2L.REMARKS
' Johnston• , • Temp well for grab,sample.
•Comity • Neal 11,.mIiflc.lI o No.(PLL ) . -
51i.J.iitudc.and Longttade in deg cs/mintiicslsccandsOr dccilil:11(legrees: 22.CcrtitieatIon:
(If cell field,ork 1:117ong is snlllcicin) . • • . •
e I 35.555181. ' . . N- 78.297675 �` 4/22/2024
• . . Si oC Contractor Dale
. a• 6.Is.(are)thewell(s):.fPenniutcnt.- .or ZlTemporari' dial Pl}�,+rgrmnng thin four;:l hereby c�rrrif}dear At,mat s)Kw•rwrnl ooriTtructed 1m atratTlsart•
• math I SA NCAC.02C.0100 or'l sA NC Wme:0200 W ll Constrncrion Standards and Mai a
7.Is this a repair toaneristiogwe li DYcs• or ilIM, 'coliy.ofthirrecordhasbrienpnrridrdrrie•wiglonner.
- alfrhls'h a repair;fill out knomdr well coos;nrcrloa informal/on mil vapiahrrlie narare of lie ' . .
rtnvr tinder ill!ruvnarlr.irettun or wi the brisk of fits form. 23.Sttc diagram or additional well details: . . . ,
You msy.use the back of this page to provide additional sell-site details or.u'ell • .
S.Numheraf wells constructed: 1 constmction debiiLs. You May also attack additional pages if necessary.
- . For:iiulrlple In fecrinn or ro,i-irarer supply wells OiVLY with the sane cansrrucrlon,}'au can I'
submit imeform. ' SUBMITTAL,INST4TCTiONS. I' '. . . .
9.Total well depth below laud surface: 10 - (f,.) 24a. Par ALL Wells: Submit this faint within 3U days of completion of'well .
Fear nmadriploicells'lsr all depths ifdiWcrtat(s.Tonrplr-3@:14'owl 28311k)' • construction to the folloning;
• 10.Static water level below top of easing:.3 (ft.) Division of Water Resources;Information Processing Unit,..
• • If miler level is above cgsrry:'O"+" • • . ' 161T Mail Service Ccntcr,•Raleigh,NC 27699-I617 .
' 11.Borehole diacter.2.25" '(in.) 24b.for' Wells ONLY: In
m 'addition to sending,the fort to the address-in •
. 24a above. also.submit a copy of this fonu within 30 days of completion of well .
12.Well construction Method!DPT . construction to tiac folloniiig I
(i_c:auger.rosary,rabic aimi{pustl etc.} -'Di/Isluu of.Water Resources;Underground injection Control Program .
• FOR WATER SUPPLY WELLS ONLY: • '- 1636 Mail Service Center.iRaleigll,NC27699-1636
• 13;1 Yield(gpnt) 'IcHiod nt trsti 24e,-For Water Supply&Injection Wells:
• , Also'submit one copy of•this'form"Within.30 days of completion of
• 13b.Disinfection hype: ' • - • Amount: well constnrction to the coinay health department of die.eonnly.whcrc
• constricted. '
FensGW-L . North Carolina Departritent of Eminnouctu and Batumi Re:sources-Division at-Water Roo.roi . RevisedAlgust2u13
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